1. Quantitative Assessment of
Mitral Stenosis
supervised by: Dr.Hanan Al-Baker
Prepared by :
Dr.Hatem Bakarman

2. Topics Introduction. Echo indications. Scores of MS .
Assessment severity of MS.

3. 23years woman referred for possible BMV for
Rheumatic MS .
Calculate
a)mitral valve score.
b)Mean PHT.
C)MVA.
DT=583mesc
Thikness 1
Calcification 1
Subvalvular calcification1
Moblity 1 total score 4
PHT=583X0.3=175
MVA=220/175=1.3.

4. INTRODUCTION
Normal mitral valve
Two leaflets.
MVA = 4-6 cm2.

5. Introduction (causes)
RHD.
Mitral annular calcification.
Congenital.
RA – SLE.

6. (Introduction (pathogenesis
increase
LAP
MVA MGP
Pulmonary edema+
PHT
Pulmonary venous pressure
RHF
Pressure on right heart.

7. ECHO (INDICATIONS)
Class I
DX of MS & assessment of severity
Re-evaluation in patient known of Ms TTE
Assessment of LA thrombus
Evaluate severity of MS befor PMBV
Evaluation of MS when TTE is suboptimal TEE
ClassIIa
Revaluate in patient who known MS & stable clinical finding.
ClassIII
TEE is not indication routine evaluation of MS when TTE is satisfactory.
Mild MS :every 3-5 year
moderateMS:every 1-3 year
Severe MS:every 1 year
ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease Circulation 2006

8. 2-d ECHO Assessment diminish mobility & doming of Ant leaflet.
Assessment morphology of MV (scoring).
MVA (planimetry).
LA enlargement. & thrombus.
RV enlargement.
(HOCKEY STICK).

9. Doppler echo
1.PAP.
2.MVA.
3.Pressure gradient.

10. SEVERITY OF MS SEVERE MODERATE MILD SEVERITY >50mmhg 30-50mmhg
PAP
<1cm2
1-1.5cm2
>1.5cm2
MVA:
>10
5-10
<5
Gradient pressure

11. MEAN GRADIENT Unlike AS, technically easy in MS.
Reliable gradient almost always obtained with transducer at apex.
Adjust position & gain .
1.MS jet is directed toward apex so minor adjustment of transducer posotion & angulation is needed to obtain angle between doppler beam & jet
2.Gain is adjusted to clear boundry of velocity curve with well define peak & linear deceleation slope
3.Pw may provide more clear define thanCW
4.VARIATION WITH RESPIRATION

12. Calculation of Mean GradientV2 V3
Maximal Velocity
(m/sec) V1 Vn
Time
4[(V1)2 + (V2)2 + (V3) (Vn)2]
Mean Gradient = n

13. Limitation of mean gradient
Intercept angle b/w MS jet and echo-beam.
Beat-to-beat variability in arterial fibrillation.
Dependence on transvalve flow rate.
1.Low cardiac output decrease gradient pressure

14. 20 24 15 Mean Gradient Mean Gradient Varies with Length of Diastole
(mmHg)

15. MITRAL VALVE AREA 1.Planimetry. 2.PHT method. 3.Continuity equation.
4.PISA.

16. PLANIMETRY (MVA) Advantages: Limitations: May not image true orifice.
Ease of use.
Pathologic correlation.
Unaffected by MR and AR.
Limitations:
May not image true orifice.
Gain and angulations.
Calcification.
Prior commissurotomy.
1.TAKEN FROM SHORT AXIS THE IMAGE MOVE SLOWLY FROM THE APEX TOWARD BASE TO IDENTIFY THE ORIFICE OF FUNNEL SHAPED STENOTIC VALVE
1.ZOOM AREA TO FOCUS ON VALVE ORIFICE WITH GAINreduced to clearly show tissue blood border
3.Inner border of black white interface is traced to obtain valve area
4.Orifice tyipically smooth in patient with on prior procedure
Poor acoustic access.

17. Determination of MV Area
2.0
1.8
1.6
1.4
2D planimetry
1.2 1
r = 0.95
SEE = .06
p = .0001 .8 .6 .4 .6 .8 1
1.2
1.4
1.6
1.8
2.0
2.2
Operative specimen valve area
Faletra et al JACC 28:1190(1996)

18. Pressure Half time
PHT is the time interval for the peak pressure gradient to reach its half level
PHT = 0.29 x DT
1.Peak velocity ocuurs at onst of diastolic with flow decelerate in mid diastolic
2.Clear defined peak velocity is needed for accurate PHT
3.Diastolic slope should be linear with clear define edge if non linear slope is obtained the mid diastolic segment of the curve should be use for PHT

19. MITRAL VALVE AREA(PHT)
V (m/sec)
Example
DT = 750 msec
Calculate MVA
PHT = 0.3 x 750 = 225
MVA = 220 / PHT = cm2
Vmax
1.5 V1
1.0
0.5
(msec) to t1
PHT
220
PHT
MV Area =
220
DT x 0.29
MV Area =

20. Factors that May Affect P1/2T Measurement
PHT
1. Mitral orifice area.
2. Initial maximal pressure gradient.
3. LA
4. LV compliance.
5. Diastolic filling time.

21. Pressure Half time Advantages: Limitations: Ease of use.
Less angle dependent.
Not affected by orifice shape.
Limitations:
Variability(AFB)
Changing slope.
Post BMV.
Underestimate in AR & overestimate in MR.
Clear definition of Vmax and diastolic slope.
Nonlinear diastolic velocity slope.
Merging of E-A in sinus rhythm.
Influence of coexisting AI.
Changing LV and LA compliances.
immediately after commissurotomy.

22. Pressure Halftime Method in MS
Potential Problems
m/s A B C 2 1
MITRAL FLOW VELOCITY

23. Continuity Equation

24. Mitral Valve Area Limitations of Continuity Equation
More complicated than PHT method.
Transducer must be aligned parallel to flow.
Cross-sectional area of Ao or PA critical.
May underestimate MVA area in presence of MR.

25. PISA MVA=6.28Xr(2)x aliasing velocity x @ peak m.s velocity 180
Affect by alaising velocity if high >40cm/sec PISA SMALL ENOUGH NOT TO BE CONFINED MITRAL LEAFLETS

26. Comparison of MV Area By Different Methods Methods MV area (cm ) r
SEE
(cm ) 2
Methods
MV area (cm ) 2 r
Gorlin's formula
1.25
0.50
2D planimetry
1.38
0.50
0.94
0.14
Pressure half-time
1.32
0.41
0.83
0.24
TEE (jet widths)
1.31
0.53
0.94
0.13
Chen, Gillam, et al (Hamburg, Germany/Hartford,CN)
J Am Soc Echocardiogr 8:121(1995)

27. CONCLUSION
TTE indicate for revaluation in patient who known MS and change S\S
MVA planimetry affected by BMVP
PHT underestimate MS at AR & overestimate in MR
PHT affect in AFB.
COP affect on pressure gradient.

28. For those of you who slept, thanks for not snoring.